Community Health Centers bring quality care to nation's underserved

With origins in the civil rights movement and President Lyndon Johnson’s War on Poverty initiative, today’s health centers are one of the best examples of carefully targeting federal resources to deliver care to diverse and underserved communities. The community health center movement began as an innovative social experiment during the mid-1960s, and has evolved into the largest primary care network in the country. This is largely due to years of longstanding bipartisan support from both Congress and the Executive Branch that now allows health centers to serve nearly 27 million Americans each year, in nearly 10,000 communities.

Two-thirds of health center patients are people of color, and the vast majority experience myriad social factors including poverty, social isolation, and housing instability that put them at higher risk for suffering costly and deadly chronic diseases. Despite these structural challenges, the nation’s health centers continue to improve the health and wellbeing of their patients and communities, while generating $24 billion a year in savings to the healthcare system.

Delivering top notch healthcare and improving health outcomes for health center patients, who are often minority or low-income, requires an “at-all-costs” attitude. For decades, health centers have been abiding by that maxim, and today’s community health centers are using team-based care to ensure that doctors, nurses, pharmacists, and other providers can treat patients with multiple costly chronic conditions all under one roof. Community health centers recognized long ago that good health doesn’t solely come from delivering primary care services such as child healthcare, family planning, and prenatal care. It also takes creative ideas, and lots of helping hands, to deliver care that is easy, accessible, affordable, and culturally relevant for health center patients.

At every health center, transportation services are available for patients without cars or access to public transportation; translators work with doctors to explain medical choices to non-English speakers; and caseworkers are often on hand to help patients navigate bureaucracy to secure housing or food assistance. These additional services are far outside traditional healthcare thinking, but each day they help millions of patients with little money or time to spare to access affordable care at health centers.

The ability of states to expand Medicaid eligibility requirements under the Affordable Care Act (ACA) has also been key to the recent success health centers have seen. This expanded eligibility has boosted local healthcare coverage rates in communities across the country, and also reduced the amount of uncompensated care at health centers. More importantly, with the latest enrollment period for qualified health plans in the ACA Marketplace now open until December 15, community health centers continue to perform community outreach to ensure as many people as possible are enrolled in health insurance plans. Expanded healthcare coverage has been especially crucial in health centers’ efforts to improve the health of racial and ethnic minorities ‒ especially those who reside in inner city and rural communities that other providers have largely avoided.

The secret of health centers’ success is rooted in three key features:

First, each health center is firmly grounded in its local community, and governed by a patient-majority board that ensures a focus on the community’s most pressing needs. These ‘patient democracies’ give patients a voice and a choice in how their healthcare is delivered – a feature unmatched anywhere else in our healthcare system.

Second, they make their care affordable to everyone, regardless of ability to pay, removing barriers that cause too many to delay necessary care or to use costly alternatives such as ERs.

And third, they are held to high standards for performance and accountability by the federal regulators, and by competition between health centers.

Decades after their creation in the 1960s, recent turmoil surrounding the gathering of white supremacists in Charlottesville, VA stands as a stark reminder that the nation, and health centers, have more work to do on issues of equity and inequality for racial and ethnic minorities. Community health centers continue to move with ever greater zeal and purpose to confront the racial and economic disparities in health and healthcare that seem only to have intensified in recent years, and the rest of the healthcare system appears to be slowly coming to the recognition that a broader focus on population health is vital to the wellbeing of marginalized communities. In 2016, the U.S. Department of Health and Human Services released its Healthy People 2020 report, which emphasizes the need to consider poverty, education, nutrition, employment, and numerous social factors that influence the health of low-income individuals and populations of color. Health centers are focused on addressing those challenges every day.

Health centers bring $26.5 billion in economic activity, along with much needed jobs, to the 10,000 inner-city and rural communities they serve. However, most importantly, health centers have succeeded for decades in building a powerful and effective network that stretches from coast to coast. Today’s health centers continue to hold fast to the dream that gave birth to the original community health centers in Mississippi and Massachusetts: the dream of good & affordable healthcare for everyone.

Lessons for Minority Serving Institutions for Highlighting Return on Investment

Minority Serving Institutions (MSIs) matter. This is made evident by the millions of dollars that foundations as well as the federal government invest in them every year. For instance, the Penn Center for Minority Serving Institutions received a $5.1 million grant from the Andrew W. Mellon Foundation to boost the number of Hispanic faculty across the nation. Likewise, the federal government awarded nearly $762 million to all MSIs in fiscal year 2015. MSIs enrolled 40% of all students of color in the 2013-2014 academic year, totaling approximately 3.8 million students or 26% of all college students. Yet many still are unaware or doubt the efficacy of MSIs to educate and graduate students. For this reason, the Penn Center for Minority Serving Institutions along with several partner organizations launched a data-centered campaign to highlight the multitude of MSI achievements. The campaign displayed 52 data points over 52 weeks that demonstrated how MSIs advance student success.

There are several lessons learned from the MSI data points campaign. This includes both lessons for institutions as well as for us at the Penn Center for Minority Serving Institutions.

1. Show the numbers. We can’t emphasize this point enough: MSIs must show what they do through data points. A core purpose of the campaign was to encourage MSIs to convey their strengths and accomplishments to a larger public. We saw this as especially important given the preference of most policy makers and foundations for hard data demonstrating the return on investment (ROI) of higher education institutions. For example, Historically Black Colleges and Universities (HBCUs) enrolled 8% and graduated 15% of all Black students in U.S. higher education in 2013.

2. Lack of quality data. Many colleges – not just MSIs – lack the capacity to monitor much of what they do statistically. The federal government requires many metrics to be recorded annually, information publicly available via the National Center for Education Statistics’ IPEDS surveys. Yet student-level data remains wanting and is for the most restricted-use. This makes it more difficult for researchers to better investigate and demonstrate what MSIs do and how they do it. An example of the power of student-level data to show the power of MSIs were several studies done on Texas MSIs by Stella Flores of New York University and Toby Park of the University of Florida. For instance, in one study they used private student-level data to show that graduates from Hispanic Serving Institutions (HSI) in Texas earn similar salaries to those from non-HSIs when controlling for institutional selectivity.

3. Lack of unity across MSI categories. The Penn Center for Minority Serving Institutions is the only international organization with comprehensive data on all categories of MSIs. More organizations focused on MSIs are needed. More data are needed. This is not to take away from the important work done by the many organizations focusing their energy on individual categories of MSIs; these organizations are vital. Similarly, MSIs still largely operate in silos. Perhaps more can be done to unify MSIs across federal-funding demarcation lines, especially in terms of sharing knowledge on services and data collection.

4. Advancing the measurements. While most MSI services and accomplishments are impressive, not all are as easily quantifiable measured. MSIs should consider how to better measure those qualities, potentially through surveys and interviews. MSIs could also use their creative brainpower to develop new metrics that better capture the essence of what MSIs do well. For example, Ginger C. Stull and Stephanie Carroll Rainie contend that institutions such as Tribal Colleges and Universities (TCUs) can promote atypical ROI measures created by the institutions themselves rather than from external forces. Such metrics could include critical thinking, self-esteem, leadership, and community engagement. These are areas where MSIs excel, yet they are also those that require more ingenuity to quantify.

5. Follow the money. Most MSIs face funding challenges. Though some states nudged up appropriations over the past few years, the share of total core revenues coming from the state government has been shrinking in all public institutions. It is imperative that MSIs continue to maximize alternative revenue sources. Pressure should still be applied to policymakers to maintain funding levels. Yet a windfall from nearly any state is highly unlikely. Many MSIs could apply for research funding. It’s also important to note that much of an MSI’s federal funding is awarded through competitive grants. Most of these are awarded for five years and then an MSI must apply again. Funding at the federal level via Title III and V of the Higher Education Act is not likely to change. Yet perhaps it is worth considering other ways the federal government could directly support core operations at MSIs.

6. Program evaluation. MSIs are required by the federal government to assess the efficacy of their federally funded programs based on outcome measures. More can be done to chart individual student success for both those students served in addition to those students enrolled across the entire institution. Most MSIs do not publicize the results of such evaluations or conduct more sophisticated empirical research designs to estimate the true impact of their programs for targeted student populations. Researchers from UCLA and Brown University used an advanced statistical method to measure the impact of a federally-funded MSI program in a Asian American Native American and Pacific Islander Serving Institution (AANAPISI). Their study incorporated student-level data to carefully demonstrate the positive impact of the MSI program on student success in a California AANAPISI community college across several outcome measures.

For more ideas about data collection and highlighting the impact of MSIs on a larger scale, see our new report on return on investment and MSIs, which includes ample suggestions across MSIs as a whole and within individual sectors.

Note from Robin Carle, The Sullivan Alliance’s COO and Executive Director: On September 15th, our esteemed board member Dr. Wayne Riley became the 17th President of the SUNY Downstate Medical Center. We are so delighted – for him and for his institution and the community! Dr. Sullivan was proud to be a featured speaker at the inauguration ceremony. We’ve included Dr. Sullivan’s inaugural event remarks in this month’s blog. Please join us in wishing Dr. Riley hearty congratulations!

“Chairman Carl McCall, members of the Board of Regents, faculty, students, staff, alumni, and friends of this historic medical center, I bring you greetings and I salute you for the new leadership you have chosen for this institution; Wayne J. Riley, MD.

I first met Wayne Riley in January 1993, when I returned to Morehouse School of Medicine as its President, following the completion of my tenure as U.S. Secretary of Health and Human Services during the Administration of George H. W. Bush. Wayne was President of the senior class and was student body president as well. He met with me to welcome me back to the medical school and to discuss some student issues. At the conclusion of our meeting, I asked Wayne what were his career plans?

He stated that he would be going to a residency program in internal medicine at Baylor College of Medicine in Houston. I then asked what his long-term plans were. He hesitated, then looked me straight in the eye and said, “Well Sir, I really want your job. I want to be president of a medical school.”

Well, Wayne, you have succeeded in reaching your goal – not once, but twice: First as president of Meharry Medical College, where you had an outstanding seven-year tenure of leadership, and now as the 17th president of Downstate Medical Center, one of the nation’s largest academic health science centers. Along the way you have also served as president of the American College of Physicians, and as Chairman of the Administrative Leadership Council of the National Academy of Medicine, in the National Academy of Sciences.

Signs of your leadership skills were apparent when you served as chief of staff to New Orleans Mayor Mark Morial prior to your entry to Morehouse School of Medicine.

I know that you will extend your leadership tradition here at Downstate, during this time of significant change, turbulence and uncertainty in the nation’s healthcare system and at this time of challenge to our nation’s core ideals of equality and opportunities for personal growth and development.

The Morehouse School of Medicine, your medical alma mater is proud of you and your equally-talented wife, Charlene Dewey, also an alumna of Morehouse School of Medicine. For, we know you are prepared to lead Downstate Medical Center to excellence in patient care, to outstanding training programs in medicine and public health, and to innovative research to improve our knowledge of human biology.

Congratulations to you and to SUNY Downstate Medical Center on the Partnership you have created, to improve the lives of our citizens – in Brooklyn and beyond.”

Dental therapists in Alaska Native communities are making a difference

Note from The Sullivan Alliance’s COO Robin H. Carle: This month’s guest blog author Donald L. Chi is a board-certified pediatric dentist and Associate Professor of Oral Health Sciences at the University of Washington School of Dentistry. His new study shows positive long-term outcomes for individuals in communities served by dental therapists in Alaska’s Yukon Kuskokwim Delta and supports the expansion of dental therapy programs into other states to address dentist shortages and improve access to dental care for underserved communities. Before he goes into details about the study, he first shares how he became interested in this important topic.

I first learned about dental therapists in 2006, when I was a fourth-year dental student at the University of Washington. Alaska Native communities and indigenous leaders had come to the University of Washington (UW) School of Dentistry in Seattle to ask the university to house the nation’s first dental therapist training program. At first, many of my classmates and I were skeptical. We were just finishing eight years of education beyond high school and some of us were going into residency programs for even more training. It was hard to imagine how someone with just two years of post-secondary schooling could do procedures on patients that had taken us at least four times as long to figure out. For the time being, I set aside my feelings and went to the scientific literature for answers.

Dental therapists, I learned, were active members of the dental workforce in many other countries. They could help solve a major public health crisis in Alaska Native communities caused in part by dentist shortages. Alaska Native children were many times more likely to develop tooth decay and to have untreated tooth decay. Untreated tooth decay could lead to serious problems: pain, facial disfigurement, difficulties eating and sleeping, missed school days, poor grades, hospitalizations, and in rare cases, death. Alaska Native communities were remote, spread out, and sparsely populated, which led to dentist shortages. These shortages required many Alaska Native children and adults to go without treatment until there was a problem, like a toothache or abscess, at which point they would travel long distances by airplane to seek emergency dental care. To me, dental therapists seemed like a sensible solution. But, there was strong opposition from dentists and dental associations, like the way the medical profession was initially against physician assistants. In the end, the UW passed on an opportunity to make a difference.

Back in 2006, the dental literature couldn’t provide all the answers and legitimate concerns were raised. Would the care provided by dental therapists be safe? Would the quality of care be similar to care provided by dentists? Could dental therapists meaningfully improve access to dental care in underserved communities? Since then, several studies from Alaska have shown care provided by dental therapists is safe and as good as care provided by general dentists. Until now, the longer-term effects of dental therapists had not been studied, mainly because Alaska’s dental therapist program was relatively young.

Our team examined 10 years of data from the Yukon Kuskokwim Health Corporation’s dental clinic and the Alaska Medicaid program – beginning in 2006, the year in which Alaska’s dental therapists starting practicing. For each community in the Yukon Kuskokwim Delta, we counted the number of days a dental therapist provided treatment in that community. The outcomes we looked at separately for children and adults were tooth extractions, preventive care, and use of general anesthesia. General anesthesia is reserved for young children with extensive dental treatment needs and takes place in a hospital, where the child is put to sleep and all the necessary dental treatment is provided at once.

We asked two questions. First, what is the relationship between the number of dental therapist treatment days and each outcome? This question would assess the overall impact dental therapists have had in Alaska Native communities. Second, what is the difference in outcomes for communities with the greatest number of dental therapist treatment days and those with the no dental therapist treatment days? This question would give us a sense for how big a difference in outcomes could be expected by introducing dental therapists into communities.

In terms of the answer to the first question, we found dental therapists are having a positive impact on communities. Children and adults living in Alaska Native communities served more intensively by dental therapists had significantly lower rates of tooth extractions and higher rates of preventive care. In terms of the general anesthesia outcome, there were differences between the two datasets. The health record data showed significantly lower rates of general anesthesia associated with dental therapists, whereas in the Medicaid data the relationship was not statistically significant. A conservative conclusion is that dental therapists did not lead to increased rates of dental treatment under general anesthesia for young children.

For the second question, there were differences in outcomes between communities served most intensively by dental therapists and communities with no dental therapists. Child and adult preventive care utilization rates were 9.3 to 16.4 percentage points and 2.4 to 11.8 percentage points higher in communities with the highest number of dental therapist treatment days, respectively, compared to communities with no dental therapist treatment days. Child extraction rates for children were 5.4 to 15.2 percentage points lower, child general anesthesia rates were 2.4 to 3.1 percentage points lower, and adult extraction rates were 2.5 to 13.5 percentage points lower in communities with the highest number of dental therapist treatment days. These data are further evidence that dental therapists, when given the opportunity to serve communities, can make meaningful differences.

In the next phase of this study, we will travel to Alaska Native communities and talk with individuals treated by dental therapists. These shared stories will give us greater insight on the impact dental therapists have had on individual lives. Equally important, these narratives will give us clues on how we can make an effective program that works even better.

Moving forward, I hope scientists and public health researchers will continue studying dental therapy models to help expand our knowledge base and generate the data needed for evidence-based dental practice guidelines and policies. These data will be essential in guiding policymakers toward evidence-based legislation that improves health outcomes for vulnerable populations. Even with our study findings, I anticipate there will be continued pushback against dental therapists fueled by emotions, protectionist mindsets, and self-interest. However, I remain optimistic that we will continue to make progress toward oral health equity for Alaska Native and other underserved communities. Please contact me if you would like to learn more about our dental therapist study or other ongoing research studies in Alaska.

Help Us Build a Diverse and Culturally Competent Health Care Workforce

Across the United States, more than 60 million Americans live in areas without enough health care providers—doctors, nurses and nurse practitioners, physician assistants, translators, etc.—to meet the population’s needs. These health workforce shortages can be found in every state, from big cities to small towns to more rural areas. Primarily, however, they impact minority and low-income communities, where people are more likely to be uninsured and suffer disproportionately from chronic disease. Ultimately, the lack of access to care within these communities translates into worse health outcomes. Disparities in the access to and the quality of health care has a devastating impact on the collective health, wellness and life expectancy of people living in these communities, at a cost of billions of dollars in unnecessary health spending and lost productivity to the nation’s economy.

The Role of an Urban Academic Institution in Improving Health Equity

But there are steps that we can take to make sure these communities’ needs are met and a diverse and culturally competent health workforce is created to serve everyone in the U.S. regardless of where they live. At the Urban Universities for Health Equity through Alignment, Leadership, and Transformation (HEALTH)—a partnership between the American Academy of Medical Colleges, the Association of Public and Land-grant Universities, the Coalition of Urban Serving Universities, and the National Institutes of Health—we believe universities can play a large role in addressing health disparities by educating a workforce that meets their community’s needs. But they need more information to guide their decisions.

Our new Metrics Toolkit can help universities graduate health professionals that are diverse and culturally competent—providers that understand their patients’ needs and are equipped to address them. The toolkit is interactive and web-based, with the goal of helping universities measure their efforts in this area, while providing university leaders with evidence-based strategies, indicators and measures. The toolkit is customizable to fit each university’s mission and the unique needs of their community, and can help improve internal reporting to track their progress and build their capacity to collect data.

The Toolkit was launched recently via a webcast, which was attended by hundreds of university leaders, funding agencies, heads of health professions and higher education associations, and several other national stakeholders. The recording of the webcast is now available, and we encourage you to watch it and share with your colleagues. A three-minute YouTube video is also available for people who want to learn more about the project.

The site also includes case studies from the Urban Universities for HEALTH demonstration sites to highlight best practices using the strategies and data in the toolkit. For instance, we’ve profiled efforts at the University of Cincinnati and Cleveland State University and Northeast Ohio Medical University, which highlight strategies the institutions used to meet their diversity goals through the admissions process. We also explore an initiative at SUNY Downstate Medical Center to prepare multilingual providers for the diverse community of new Americans that it serves in Brooklyn, New York, and efforts by the University of New Mexico to use the legislative process to improve health workforce data collection across the state.

Finally, I encourage anyone who is interested in addressing health care disparities to share the Metrics Toolkit with your colleagues. And if you have any questions about how it can be used to build a diverse and culturally competent health care workforce, feel free to contact us at info@urbanuniversitiesforhealth.org. By working together, collecting needed information and sharing best practices, we can ensure that the health needs of all Americans—regardless of race/ethnicity, primary language, location, or socioeconomic status—are met and addressed fully.

“I bring greetings, and good wishes to the president, the deans, and the faculty, staff and students of the University of Minnesota Academic Health Center; and, for the members of the Class of 2017, for your family, your supporters and your friends, I give you my congratulations! Congratulations on achieving this personal and professional milestone in your life. This is the result of your many years of hard work, of commitment and of sacrifice. You have all grown in stature, in knowledge and in wisdom at this university. You will leave today as educated, recognized health professionals.

You enter the health professions at a time of significant growth, increasing demands from our citizens for services, continuing innovations and – great uncertainty. As a society, we are trying to reconcile two competing value systems. On the one hand, in America we pride ourselves on our personal independence, our freedom from want and, our self-reliance. On the other hand, we are wrestling with the question of, if – and how much – we should depend upon our fellow citizens to help us, particularly in times of need – for health services and for other services as well. You must add your voices and your views to this debate. For its outcome will determine what kind of society we are.

Photo by Lifetouch

Dental medicine is also experiencing innovation and change. And this school of dental medicine is leading some of that change, with the programs you have introduced in recent years for the training of dental therapists – a new professional in dental medicine. I congratulate you for your leadership in training the kind of dental professionals who will help reach those among our citizens who do not have adequate access to dental services. Partnering with their other dental colleagues, dental therapists will help to improve the oral health of Americans.

As you establish yourselves in your communities, in academic health centers, and elsewhere, I urge you to provide compassionate science and leadership to your fellowman. Great leaders have a core set of values which guide them. These values include honesty, integrity, a love of learning and respect for others. Successful leaders have a clear vision of the future they wish to achieve; and they have the courage, the commitment and the persistence to achieve it. Great leaders also inspire others to reach for great goals. They have superior knowledge and skills, they are open to new ideas, they are willing to take prudent risks, they are undaunted by failure. Indeed, they learn from their failure, and work to improve their efforts.

Through your service and your leadership, you will add value to the lives of others. And you will enrich your own life. I challenge you, Class of 2017, to continue learning – active learning throughout your lives. By so doing, you’ll remain relevant in your profession and you will be a cherished asset in your communities. Participate in the full life of your community, in political debates, in discussions about educational programs in schools – public and private; in assessing the adequacy of libraries, of recreational facilities, transportation systems, housing, air quality.

The University of Minnesota’s School of Dental Medicine 2017 Graduation — Photo by Lifetouch

Photo by Lifetouch

In other words, in addition to being a highly trained dental professional, be an active, informed member of your town or city, helping to make wise decisions for the benefit and betterment of all. Great leaders take actions which add value to the lives of others.

As you move to this next stage of your lives and your profession, remember those who helped you get to this place – your parents and other family members; your teachers and counselors, your mentors and many others, who created, and worked in, the institutions which have provided the learning environment where you have prospered.

It is now your challenge, and your opportunity to make your unique contribution to improving the lives and health of your fellowman, your community and your country. For in so doing, you will provide opportunities for those who follow in your path.

So, members of the Class of 2017, I congratulate you, I salute you for your achievements. And, I also challenge you to continue learning throughout the rest of your lives. I challenge you to be servant leaders of your generation, for our country needs you – today, and in the years to come.

Start your journey to the health professions this summer!

By Taryn Hayes, Marketing and Program Coordinator, Division for Health Sciences Diversity, Virginia Commonwealth University

Whether you are looking forward to your first day of summer vacation, or you are thinking about your first day of middle, high school or college it is never too soon to begin your journey to a career as a health care professional.

In the fall of 2016, 17.5 million students enrolled in undergraduate programs in the United States. As this number continues to increase, distinguishing yourself from other students will be crucial to your future success. How? That’s what the VCU Health Sciences Pipeline is here to answer!

The VCU Pipeline features programs and initiatives for students just like you in their journey toward a health care profession! We aim to educate, excite and expose diverse students to various health care professions by providing them with hands on experiences, resources to strengthen their academic skills and simply helping them make informed decisions while pursuing the health care profession of their choice. From Dental Hygiene to Physical Therapy, our programs explore various disciplines and give you the opportunity to learn from current college students, health care professionals and admissions faculty about the extensive and exciting options in the health care field.

Your senior year of high school or college may seem light years away but molding yourself into a competitive applicant for admissions to a health professions program can start now. As the school year comes to an end, consider how to take advantage of your free time during the summer! While you are spending your first few weeks relaxing, be sure to take time to find local organizations or causes that you are passionate about. Health care professions are characterized as helping professions and being involved in your community demonstrates your desire to serve to undergraduate health professions programs.

As a student interested in a health care profession, focusing your efforts on a health related cause or volunteering in a healthcare setting is a great idea and gives you the opportunity to bolster your resume. Taking initiative and creating your own opportunities is essential if you are interested in gaining hands-on experiences. Reaching out to local health care providers for shadowing opportunities or researching various internships are just a couple of great ways to find meaningful experiences.

Okay, now let’s talk about the tough stuff - grades. While college admissions consider more than grades, a good GPA with rigorous coursework is incredibly important. Successful college students study about 40 hours a week or more. Developing effective study skills now will be beneficial when your college roommate is frantically cramming for the biology final and you are watching your favorite Netflix series because you have been studying for weeks.

Competitive applicants demonstrate effective time management and strong interpersonal and communication skills through their engagement in extracurricular activities Whether you are on the lacrosse team or have a starring role in your school play, maintaining a good GPA while being involved demonstrates these skills to college admissions. Even if you are not eligible your freshman year, consider taking on leadership roles within your student organizations throughout your high school career.

As this academic year comes to an end, be sure to check out our website to learn about our pipeline programs and our application process. Feel free to contact us if you would like to learn more about the VCU Pipeline or if you would like to support our students!

Remember, the journey from student to health professional starts with one step. Take it with us.

Dental Therapy Gains Steam in the U.S. as Model Curriculum Becomes Available

Dental therapy is an emerging profession in the United States helping to address critical gaps in care for the tens of millions of Americans who have difficulty finding a dentist to treat them. Dental therapists—performing a caregiving role similar to physician assistants—are supervised by dentists and work as part of a team to deliver routine preventive and restorative care, including preparing and filling cavities and performing simple extractions.

Dental therapists have practiced internationally for nearly a century and now work in more than 50 countries. There are 1,100 studies of dental therapists in over 26 countries, along with evaluations in Alaska and Minnesota demonstrating that they provide care at the same level of quality as dentists for those procedures they have in common.

The U.S. is a relative newcomer to this model, yet interest at the state and national levels is growing. In 2004, Alaska began using dental therapists to provide care to Native Alaskans, many of whom live in remote villages that dentists visit infrequently. Minnesota authorized their use in 2009, and Maine and Vermont followed suit in 2014 and 2016, respectively. About a dozen state legislatures are considering similar proposals to improve care for underserved populations, including Arizona, Kansas, Maryland, Massachusetts, Michigan, New Mexico, and Ohio.

Tribal activity is also growing. In 2016, Oregon approved pilot programs allowing two federally recognized tribes to employ dental therapists. That same year the federal Indian Health Service (IHS) invited comments on a proposed policy to allow dental therapists to practice in IHS facilities across the nation. And in early 2017 Washington became the first state to pass legislation to allow dental therapists to practice in Indian country.

Dental therapists are being used in a variety of ways in Minnesota to improve care access. Dentists are hiring dental therapists to serve more Medicaid patients, finding that the lower cost of employing them makes accepting Medicaid’s discounted payment rates more palatable. Minnesota Federally Qualified Health Centers are using the savings from employing dental therapists to serve more patients and provide more free or low-cost care to uninsured people, while other clinics are deploying dental therapists to schools, nursing homes, and rural hospitals to deliver care in more convenient locations.

While legislative change is necessary to allow dental therapists to practice in states, training institutions are essential to build this workforce. To that end, early this year a model dental therapy curriculum was unveiled for community colleges and universities interested in launching such training programs. This sample curriculum, developed with input from the American Association of Community Colleges, the W.K. Kellogg Foundation and The Pew Charitable Trusts, was designed to meet dental therapy guidelines issued in 2015 by the Commission on Dental Accreditation (CODA), the accrediting body for the nation’s dental education programs.

For a number of reasons, curriculum developers are particularly interested in boosting the role of community colleges in providing this training. CODA’s dental therapy guidelines call for at least three academic years of training, without prescribing a specific degree requirement, such as a bachelor of science. Dental hygienists and assistants are also given credit for the education they have already received. This opens the door for community colleges to play a central role in training dental therapists. Community colleges are committed to addressing the educational and workforce needs of their communities and to offering affordable training for some of the nation’s most economically challenged students. Their participation could go a long way toward expanding the diversity and cultural competency of the oral health professions. Community colleges have educated the majority of the nation’s dental hygienists and are a logical home for training dental therapists—especially given that about half of community colleges are located in or near rural areas where the shortage of dentists is most acute.

As more states strengthen and modernize their oral health delivery systems by authorizing dental therapy, schools have gained an important resource to develop high quality training programs to educate this emerging workforce. Progress on both fronts is certain to benefit millions of underserved Americans.

Want to help diversify the biomedical workforce? Start with mentoring

In an opinion article for the New York Times published in August 2016, Drs. Daniel Colón Ramos and Alfredo Quiñones-Hinojosa expressed that trainees from racial/ethnic groups historically underrepresented (HU) in the biomedical sciences are exhausted, not from the research, but from the “constant bombardment of narratives and stereotypes that compromise their ability to focus on their training.” The question of how to reduce the prevalence of such deleterious narratives and stereotypes in order to support the persistence and success of HU trainees has been raised many times over in the past few decades. Yet, the philosophy of science as an objective endeavor can make it difficult for some mentors to understand how a trainee’s identity might have an impact on their research performance. Research shows that HU trainees are interested in talking about issues of race and ethnicity with their mentors, but these conversations are often avoided. How can we better prepare mentors to effectively talk about cultural diversity and sensitive topics with all scholars, especially those from HU groups?

The National Institutes of Health (NIH) has called for scientific, evidenced-based approaches to training that will broaden participation in the sciences. To answer this call, the National Research Mentoring Network (NRMN), a collaborative research effort funded by the NIH, was launched in 2014 to better prepare mentors, often white and more advanced in their careers, for effective research mentoring relationship with their mentees, who are coming from increasingly diverse racial, ethnic, gender, and socioeconomic backgrounds.

NRMN’s Mentor Training Core has worked extensively for the past few years on implementing established as well as new mentor training interventions designed to improve research mentoring relationships. Within the Mentor Training Core, we formed the Culturally Aware Mentoring (CAM) subgroup, an interdisciplinary group of individuals from varied racial and ethnic backgrounds. Our charge was to develop an advanced mentor training intervention designed to equip mentors with the skills and knowledge necessary to support a diversifying scientific workforce. We developed the CAM training content predicated upon the assumption that everyone is a cultural being and that theoretically-informed training can facilitate mentors’ cultural awareness and capacity to effectively respond to diversity matters in their research mentoring relationships.

The past two years of work have culminated in a six-hour intensive training and an introductory online module that is completed prior to the training. The training is designed to be an advanced workshop for mentors who have already completed some form of mentor training. Training participants are invited to look inward and examine their own racial and ethnic identity; this awareness-raising helps participants to identify their personal assumptions, biases, and privileges that may operate in their research mentoring relationships. Through a combination of activities including group discussion, case studies, and role play, mentors have the opportunity to learn and practice culturally aware mentoring skills. At the conclusion of the workshop, mentors are encouraged to think of one thing that they can do in their mentoring relationships to be more culturally aware and respond better to cultural diversity matters in those relationships.

The training has been pilot tested at four separate sites with 82 mentors and 30 facilitators from a range of disciplinary backgrounds and career stages. Data from our workshop evaluation survey suggest that mentors experience significant gains in several skill areas, including their perceived ability to intentionally create opportunities for their mentees to talk about their lived experiences as they relate to research. Specifically, mentors who participated in our workshops have reported significant perceived skill gains in several areas relating to culturally aware mentoring:

intentionally creating opportunities for mentees to bring up issues of race/ethnicity;

thinking about how the research experience might differ for mentees from different racial and ethnic groups;

knowing when it is appropriate to raise the topic of race or ethnicity in mentoring relationships; and

having strategies to address racial and ethnic diversity in mentoring relationships.

In open-ended responses, mentors noted that “This topic is important and worth the time it takes in meeting (e.g., building in time in meeting for discussion)” and that “This type of training is doable! (I doubted it before).” Such responses convey that mentors perceive this training as a step beyond the typical diversity training, with the potential to have a lasting impact on mentors’ perceptions and actions with respect to mentoring relationships. The CAM training shows promise as a strategy for reducing the negative stereotypes and narratives that can challenge the research experiences of historically underrepresented trainees.

The CAM subgroup is led by Angela Byars-Winston (University of Wisconsin-Madison) and includes Amanda Butz (University of Wisconsin-Madison), Rick McGee (Northwestern University), Sandra Quinn (University of Maryland College Park), Carrie Saetermoe (University of California Northridge), Stephen Thomas (University of Maryland College Park), Emily Utzerath (University of Wisconsin-Madison), and Veronica Womack (Northwestern University). Individuals interested in having the CAM workshop come to their institutions should contact the Mentor Training Core at mtc@nrmnet.net.

Each of our State Alliances has been developed by leaders who understand the unique strengths and particular needs of their state’s citizens as well as the varied educational, business, governmental and local communities’ priorities. Yet, for the many differences in state and regional environments, we find there are many common interests and barriers experienced by our leaders. This month we highlight some of the activities of our North Carolina Alliance, NCAHPD. The enthusiasm, activities and continued expansion of this community of leaders is making a difference in our collective efforts to improve the diversity and equity within our nation’s health workforce. Thank You!

We are happy to report that the North Carolina Alliance is going strong. We hold quarterly meetings at member schools, which are preceded with a 2-hour continuing education session that informs us of the diversity work happening on that campus. During the past two years, we have visited Western Carolina, High Point, East Carolina, UNC Wilmington, UNC Greensboro East Carolina, and Duke University. Our shared commitment to a diverse health professions workforce is strong, emanating from the President/Chancellor level, Chief Academic Officers, Chief Diversity Officer, faculty and staff. On average, 25 to 30 alliance representatives attend our meetings where we have learned how each institution is creatively responding to the desire to increase diversity among their student body and faculty. In some cases, alliance members have offered advice on addressing problems encountered. In addition to quarterly meetings, the NC Alliance has maintained an up-to-date website which features state-wide Summer Enrichment Programs for High School and College students who are interested in pursuing a health career. If you are interested in a career in healthcare, please check out our site to plan your summer!

We are pleased to announce an exciting conference being planned by our active alliance members. The fourth biennial conference of the NC Alliance will be held on March 22-24, 2017 at the Grandover Hotel in Greensboro, NC. We hope you can join us! The theme of this year’s conference is “Closing the Gaps: Exploring Evidence-Based Practices to Enhance Health Professions Diversity.” This three-day event will showcase best practice models and strategies that have proven successful in recruiting and retaining students in health professional programs as well as maintaining a diverse workforce setting. The audience is expected to include faculty of state-wide higher education institutions, state-wide health officials, and representatives from various health organizations, as well as college students who desire to network and increase their knowledge on health professions diversity.

The first day of the conference is dedicated to a recruitment seminar for health professions students and advisers. Community-college students will attend and meet faculty of various university health programs to learn more about admission requirements. The following two days will include keynote presentations and panel discussions by leaders in higher education and the healthcare industry. There will be a competitive poster presentation session for students with prizes and opportunities for networking and collaborating with others around the state. All conference participants will receive a copy of the Journal of Best Practices in Health Professions Diversity: Research, Education and Policy. During the conference, we will be signing additional organizations to the alliance. We could potentially reach 25 members.

The work of the NC Alliance continues to be important. The racial/ethnic diversity of North Carolina’s health care professionals falls short of matching the state’s population diversity. According to 2014 report on Diversity in the Health Professions by researchers at the Sheps Center, white providers made up more than 80% of licensed health professionals in the state, yet they represented 64% of the population. The underrepresentation was worse for blacks who comprised 22% of the state’s population. Only in the LPN workforce is the group overrepresented. As the AAMC noted in 2015, fewer blacks enrolled in medical school that year than in 1978. It is concerning to note the slower growth especially among black physicians. While we celebrate the increase among African American female physicians, it is important to encourage the growth among males. There is also the opportunity to promote health professions diversity among the growing Hispanic groups which now comprises 9% of the population. Although relatively young, this population represents less than 3% of all health professionals in the state.

We appreciate this opportunity to highlight work of the North Carolina Alliance and invite interested parties to attend our quarterly meetings -- and the upcoming biennial conference. We hope to see you in March!

Nurse Practitioners can transform primary care NOW

A commitment to primary care has long been established as a way to begin to close the healthcare disparities in the United States; specifically to move from an illness model of care delivery to a framework that supports wellness. However, despite the legislative changes, such as the Affordable Care Act (ACA, 2010) and social movements across the nation promoting health and wellness, we continue to see gaps in quality and disparities in health outcomes that impact the individual and their families. Unfortunately we also continue to see challenges directly related to access. Despite the improvements to the system, there remains a lack of access of providers in certain regions of the country and to certain demographic populations. While there are an estimated 20 million more Americans gaining health insurance coverage under the ACA, it created a challenge to an already fragile primary care system, especially for vulnerable populations in already medically underserved communities (U.S. Department of Health and Human Services, 2016).

In its 2010 National Healthcare Disparities Report, the Agency for Healthcare Research and Quality (AHRQ) concluded that there was a need to increase the progress of achieving better quality of care and more equitable care for all.

Specifically, the report outlined the following:

Healthcare quality and access are suboptimal, especially for minority and low-income groups.

Quality is improving, access and disparities are not.

Urgent attention is warranted to ensure improvements in quality and progress in reducing disparities with respect to certain services, geographic areas, and populations

Disparities in preventive services and access to care

Progress is uneven with respect to eight national priority areas:

Two are improving in quality: 1) palliative and end-of-life care and 2) patient and family engagement

Three are lagging: 3) population health, 4) safety and 5) access

Three require more data to assess: 6) care coordination, 7) overuse and 8) health system infrastructure

Nurse Practitioners (NP) are primary care providers with graduate (masters and doctoral) academic and clinical preparation to provide care to individuals and populations that includes health promotion, disease prevention, diagnosis of disease and management of chronic conditions. Drs. Loretta Ford and Henry Silver (interestingly enough a nurse and physician) developed the first NP program at the University of Colorado in 1965. The Massachusetts General Nurse Practitioner Program, also directed by a nurse and physician team began in 1968. Since that time, NP programs have increased to meet the demand for access to quality healthcare and currently there are approximately 350 NP programs in the U.S. For over 50 years, research has consistently shown that NPs provide high quality, cost effective primary, acute and long-term care.

Statistics used with permission from “Eye on Health” by the Rural Wisconsin Health Cooperative, from an article entitled “Rural Health Can Lead the Way,” by former NRHA President, Tim Size: Executive Director of the Rural Wisconsin Health Cooperative

In the 2015 Assessing Progress on the IOM Report, The Future of Nursing, there is continued emphasis regarding the importance of ensuring that the nursing workforce be fully involved in the transformation that will ultimately shift the care delivery system. In fact, the promotion of the use of Advanced Practice Registered Nurses (APRNs) or Nurse Practitioners to the full extent of their education and training, along with collaborative practice models is foundational to the report. Despite the consistent and convincing evidence that leads to the logical conclusion to expand the use of NPs to improve access to high quality, cost effective primary care, one major impediment addressed in the IOM report, is the restriction of full practice for NPs in many states. Currently, only 19 states and the District of Columbia allow for full independent practice. The remaining states have reduced (19) or restricted (12) practice.

Nurse Practitioner State Practice Environment

In addition to the Institute of Medicine, other prestigious groups such as the Federal Trade Commission, VA System, Robert Wood Johnson Foundation, National Governors Association and American Association of Retired Persons have advocated for reduced barriers for NPs. In spite of this support the American Medical Association and American Academy of Family Physicians continue to oppose full independent practice for NPs citing concerns about safety and quality (which is unsupported by data).

The enrollment and graduation rates in NP programs has continued to increase with approximately 14,000 new NPs graduating in 2014 compared to 6,556 graduates in 2005-2006 (AANP, 2016). Conversely, 50% of medical students chose primary care in the 1990s, whereas only 20-25% choose primary care now (West and Dupras, 2012). This change in graduating medical students choosing primary care is believed to be attributed to a perceived unfavorable lifestyle with being a primary care physician (Haver et. al, 2008). However, today there are more than 205,000 NPs practicing in the U.S., 87% of whom are prepared in primary care.

To contribute to the needs outlined in the 2010 AHRQ report, NPs have increased access to care by treating those with Medicaid, Medicare and without any source of payment. Specifically, 85% of NPs treat people with Medicare, 84% treat people with Medicaid, and approximately 60% of Family Nurse Practitioners and Advanced Practice Nurses treat people without a source of payment (AANP, 2016).

NPs are more likely than other primary care disciplines to practice in underserved rural and urban communities. Both settings have similar healthcare disparities and barriers to healthcare. Periyakoil (2010) provides a national picture of urban and rural health that illustrates the need for a better distribution of primary care providers who can address barriers and reduce health disparities.

We believe that we must return to the roots of the NP movement which was started and supported by physicians and get beyond “long-simmering disputes over ‘turf’” (NIHCM, 2014) to allow NPs (and others like Physician Assistants) to practice to the full extent of their education and training all over the United States. No one disputes that there are not enough primary care physicians, an increased demand for primary care services and a projection for both situations to worsen. NPs are a viable, evidenced based solution to this current and impending crisis. Let’s all forget our professional self-interests and focus on the real goal: Every American deserves high quality, cost-effective healthcare by their provider of choice. Acceptance of the critical role of Nurse Practitioners in primary care’s time has come.

Full PracticeState practice and licensure law provides for all nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications—under the exclusive licensure authority of the state board of nursing.This is the model recommended by the Institute of Medicine and National Council of State Boards of Nursing.

Reduced PracticeState practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice. State law requires a regulated collaborative agreement with an outside health discipline in order for the NP to provide patient care or limits the setting or scope of one or more elements of NP practice.

Restricted PracticeState practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. State requires supervision, delegation, or team-management by an outside health discipline in order for the NP to provide patient care.

Greer Glazer is on the Board of Directors of The Sullivan Alliance. She is the Dean and Schmidlapp Professor of Nursing and Associate Vice President of Health Affairs for the College of Nursing at the University of Cincinnati.

Karen Bankston is Associate Dean of Clinical Practice, Partnership and Community Engagement for the College of Nursing at the University of Cincinnati.